conseqüências cardiovasculares da aos geraldo lorenzi-filho professor livre docente lab do sono,...

Conseqüências Cardiovasculares da AOS

Geraldo Lorenzi-Filho

Professor Livre Docente

Lab do Sono, Disciplina de Pneumologia

InCor, FM USP

[email protected]

Conflito de interess

• Laboratório do sono do InCor– Grants e colaboração– Philips-Respironics– Resmed– Fisher-Paykel– Equipamentos

– FAPESP, Fundação Zerbini, CnPq, Finep

Prevalência de Distúrbios Respiratórios do Sono entre as Doenças Cardiovasculares

HipertensãoHipertensão

35%35%

Hipertensão Hipertensão RefratáriaRefratária

70%70%

Doença Doença CoronarianaCoronariana

Fibrilação Fibrilação AtrialAtrial

Insuficiência Insuficiência cardíacacardíaca

50%50%

50%50%

30%30%

Leung. AJRCCM 2003

SaO2SaO2

94%94%78%78%

SNORESNORE

OBSTRUTIVEOBSTRUTIVE

APNEAAPNEA

Polissonografia

De que forma a AOS pode afetar o SCV?

SaO2SaO2

94%94%

SNORESNORE


APNEAAPNEA

SaOSaO22SaOSaO22SaOSaO22

SaOSaO22

COCO22COCO22COCO22

COCO22


SaO2SaO2

94%94%78%78%

AROUSALAROUSAL

SNORESNORE


APNEAAPNEA


SaOSaO22

COCO22COCO22COCO22

COCO22


SaO2SaO2

94%94%78%78%

AROUSALAROUSAL

SNORESNORE


APNEAAPNEA


SaOSaO22

------------

--------

----

COCO22COCO22COCO22

COCO22

CPAP--------------------------

CPAP OSA

APNEIA OBSTRUTIVA DO SONO

Conceitos

• Hipertensão Arterial Sistêmica

• Arritimia Cardíaca

• Mortalidade

• Aterosclerose

CPAP and BPCPAP and BP

Before Before AfterAfter

Pepperell JC et al. Lancet. 2002;359:204-10.Pepperell JC et al. Lancet. 2002;359:204-10.

OSA OSA

Cause of Cause of HypertensionHypertension

11


Conceitos

Hipertensão Arterial Sistêmica

• Arritimia Cardíaca

• Mortalidade

• Aterosclerose

SAOS e arritimia: Fibrilação Atrial

Kanagala R et al. Circulation 2003Kanagala R et al. Circulation 2003

Rec

orrê

ncia

de

Rec

orrê

ncia

de

FA

apó

s 12

F

A a

pós

12

mes

esm

eses

0102030405060708090

100

Controles SAOS tratado SAOS nãotratado

P=0.46P=0.46

P=0.009P=0.009

P=0.013P=0.013


Conceitos


Arritimia Cardíaca

• Mortalidade

• Aterosclerose

SAOS e Morte SúbitaSAOS e Morte Súbita

Gami et al Gami et al N Engl J Med. 2005;352(12):1206-14N Engl J Med. 2005;352(12):1206-14..

OSA and fatal cardiovascular eventsFollow up 10 years

Marin JM et al Lancet 365: 1046-1053, 2005Marin JM et al Lancet 365: 1046-1053, 2005

264 377

403 235

372

1,651

OSA and fatal cardiovascular events

Marin JM et al Lancet 365: 1046-1053, 2005Marin JM et al Lancet 365: 1046-1053, 2005

Number HR (IC) Cohort Publication

1,651Heathy subjectsSevere OSA(n= 235)

2.87 (1.17 – 7.51)

Spain Follow up

10 y

J Marin Lancet2005




2.87 (1.17 – 7.51)

Spain J Marin Lancet2005

Wisconsin Cohort: Population Based Study 1,522 subjectsWisconsin Cohort: Population Based Study 1,522 subjects

Young T et al, SLEEP 31(8): 1071-1078, 2008Young T et al, SLEEP 31(8): 1071-1078, 2008




2.87 (1.17 – 7.51)


1,522No OSASevere OSA(n = 63)

3.8 (1.6 – 9.0)

Wisconsin

Follow up18 y

Young TSLEEP2008




2.87 (1.17 – 7.51)



3.8 (1.6 – 9.0)

Wisconsin

Young TSLEEP2008

Sleep Heart Health Study 6,441 subjects from different cohorts across USA Sleep Heart Health Study 6,441 subjects from different cohorts across USA

Punjab N et al PLOS: 6 (8) e 100132, 2009Punjab N et al PLOS: 6 (8) e 100132, 2009




2.87 (1.17 – 7.51)

SpainFollow up

10 y

J Marin Lancet2005


3.8 (1.6 – 9.0)

WisconsinFollow up

18 y

Young TSLEEP2008

6,441No OSASevere OSA(n= 341)

1. 5 (1.1 – 1.9)

SHHSFollow up

8.2 y

PunjabPLOS2009


Conceitos


Arritimia Cardíaca

Mortalidade – Estudo SAVE

• Aterosclerose

Arterial Stiffness Arterial Stiffness Pulse wave velocity (PWV)Pulse wave velocity (PWV)

A D B

A

B

T

CCACCA

CRCRCFCF

RARA

FAFA

Echo-trackingEcho-tracking

Intima media thickness (IMT) Intima media thickness (IMT)

Carotid diameterCarotid diameterANTANT POSPOSTT

OSA »»atherosclerosis ?

OSAOSA HTNHTN

• Male Age• Hypertension• Dislipidemia• Diabetes

No co-morbidities

~ 50% of OSA - HTN~30% of HTN - OSA

Arterial StiffnessArterial Stiffness

8

8,5

9

9,5

10

10,5

11

11,5

12

12,513

Control OSA HTN OSA + HTN

PW

V (

m/s

)P

WV

(m

/s)

8,78,7

10,710,710,110,1

12,112,1

<0.001<0.001

<0.001<0.001

<0.007<0.007

NSNS<0.001<0.001

<0.007<0.007

Drager LF et al. Chest 2007;131:1379-1386Drager LF et al. Chest 2007;131:1379-1386n = 15 15 15 15

OSA and LV OSA and LV hypertrophyhypertrophy

Drager LF et al. Chest 2007;131:1379-1386Drager LF et al. Chest 2007;131:1379-1386

60

70

80

90

100

110

120

130

Control OSA HTN OSA+HTN

**

LV

ma

ss in

de

xL

V m

ass

ind

ex **

**** *P<0,05*P<0,05

n = 15 15 15 15

Carotid Intima Media Thickness Carotid Intima Media Thickness ((m)m)

Drager LF et al. Hypertension 53: 64-69 2009Drager LF et al. Hypertension 53: 64-69 2009n 22 25 20 27

Carotid DiameterCarotid Diameter ( (m)m)

Drager LF et al. Hypertension 53: 64-69, 2009Drager LF et al. Hypertension 53: 64-69, 2009

n 22 25 20 27

Carotid Distensibility (KpaCarotid Distensibility (Kpa-1-1 10 10-3-3))

Drager LF et al. Hypertension 53: 64-69, 2009Drager LF et al. Hypertension 53: 64-69, 2009n 22 25 20 27

The impact of continuous positive The impact of continuous positive

airway pressure (CPAP) on airway pressure (CPAP) on

validated markers of validated markers of

atherosclerosis. atherosclerosis.

Drager LF et al. Drager LF et al. Am J Respir Crit Care Med.Am J Respir Crit Care Med. 2007;176:706-12. 2007;176:706-12.

MethodsMethods

No treatment (NT)No treatment (NT)

(N=12)(N=12)

24-h blood pressure monitoring24-h blood pressure monitoringSerum catecholamineSerum catecholamine

C-reactive protein C-reactive protein

VASCULAR PARAMETERSVASCULAR PARAMETERS

24 OSA patients AHI>3024 OSA patients AHI>30

CPAPCPAP

(N=12)(N=12)

4 months4 months

RandomizationRandomization

Baseline Baseline

Pulse Wave Velocity

Arterial Stiffness

BaselineBaseline 4 months4 months

OSA-NTOSA-NT OSA-CPAPOSA-CPAP

NSNS

77

88

99

1010

1111

1212

1313

PW

V (

m/s

)P

WV

(m

/s)


P=0.002P=0.002

PW

V (

m/s

)P

WV

(m

/s)

77

88

99

1010

1111

1212

1313

P<0.001P<0.001


Intima-media thickness



NSNS


P=0.04P=0.04

P=0.02P=0.02

IMT (

IMT (

µm

)µ

m)

400400

500500

600600

700700

800800

900900

10001000

11001100

12001200

400400

500500

IMT (

IMT (

µm

)µ

m)

600600

700700

800800

900900

10001000

11001100

12001200


Carotid Diameter



NSNS


NSNS

NSNS

55005500

Caro

tid

dia

mete

r (

Caro

tid

dia

mete

r ( µ

m)

µm

)

60006000

65006500

70007000

75007500

80008000

85008500

90009000

95009500

55005500

Caro

tid

dia

mete

r (

Caro

tid

dia

mete

r ( µ

m)

µm

)

60006000

65006500

70007000

75007500

80008000

85008500

90009000

95009500


Conclusão

• AOS é pouco diagnosticada, e quando não tratada faz muito mal .....

• OBRIGADO!• [email protected]

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